Form simplifies return to work, duty instructions

A single form can be used for requesting an employee examination and reporting modified duty restrictions and return-to-work plans, which streamlines much of the paperwork necessary in occupational approach. That’s a tip from Ada Fisher, MD, MPH, chief of occupational health services at the Veterans Administration (VA) Medical Center in Salisbury, NC.

Fisher first developed the form with some colleagues in private industry in 1990 and adopted the form for use in the VA center in 1997. With minor modifications, she says the form could be used by occupational health programs working with private industry. (See sample of form, pp. 4-5.)

"The form is very simple, and all the information you need is right there," Fisher says. "It tells us what the person can and can’t do, where to bill, and it says that unless the person is dead, send em back to work."

Before adopting the form, the VA center was using a 3-by-5 slip to write a note to the supervisor about restrictions. That usually resulted in brief notes that didn’t tell the supervisor much. The new form provides more information on one page.

The "occupational health report to supervisor" is a four-copy form printed on front and back. The front is a form that allows the employer to request an examination. The occupational health provider uses the same form to indicate the return-to-work plans and any job restrictions.

The employee’s supervisor fills out the top section with the employee’s identification and section A indicating what type of examination is requested. (Or the form can originate in the occupational health clinic, with the provider starting the form once the exam is requested.) The back of the form provides brief instructions for how to determine what category the visit fits into. Section A also includes the supervisor’s authorization of the exam.

After the exam, the provider uses section B of the same form to indicate that the employee is not able to return to work, can return to work on a certain date, and/or is able to return to work with certain restrictions. The restrictions section offers eight categories and refers the user to the back of the form for explanations. For instance, the "physical" restriction category explains that "any limitation of motion to a body part must be specified or the activity which is limited must be described, e.g., no bending, stooping, or ladder climbing over 20 feet. Lifting, pushing, pulling, or torquing should be specified in terms of pounds, etc."

That section encourages the physician to be very specific in describing restrictions, a benefit that is especially useful if the employee is seeing a non-occupational medicine specialist, Fisher says. Section B also requires effective dates for the restrictions, specifying that they must not exceed 90 days.

The bottom of the form also allows the provider to note when the patient should be seen for follow-up. A box in the upper right allows the user to indicate where bills should be sent, dependent on what type of injury or illness is being treated. It also indicates that the employer provides modified duty. The original is filed in the occupational health department, one carbonless copy is given to the employee, one is sent to the supervisor, and the fourth copy can be sent to industrial hygiene, human resources, or any other place that needs a copy.

Some modifications may be needed before using the form in your own program, but Fisher says the basic format of the form should eliminate redundant paperwork while encouraging better documentation of examination results.

Editor’s note: Because the VA is a federal institution, no copyright permission is needed to reproduce and use the form in your own program. The February issue of Occupational Health Management will include another form used by Fisher: a medical evaluation form that includes a list of applicable hazards in the workplace.


For more information on the form, contact:

Ada Fisher, Chief of Occupational Health Services, VAMC Salisbury, 1601 Brenner Ave., Salisbury, NC 28144. Telephone: (704) 638-9000.